Obstetrics and Gynecology - A.M. Hromova 2000

Operative Obstetrics
Fetal Destructive Operations
Craniotomy

A surgical Procedure used to reduce the volume of the leading or trailing fetal HEAD, followed by its extraction in a reduced state. It can be performed on a stillborn fetus, and in exceptional cases, on a live fetus.

Indications for craniotomy:

1. A dead or non-viable fetus with severe malformations in cases of clinically or Anatomically Contracted Pelvis, uterine inertia, cicatricial strictures of the Vagina, or vaginal tumors, leading to prolonged obstructed labor.

2. A maternal life-threatening condition in the presence of a dead fetus, unfavorable head engagement, brow presentation, Litzmann's presentation, and the lack of conditions for Cesarean Section, vacuum extraction, or application of Obstetric Forceps.

3. Maternal conditions requiring immediate delivery (cardiovascular diseases, Eclampsia, certain cases of abruptio placentae, etc.) in the event of fetal demise.

Indications for craniotomy in a live fetus arise very rarely—only in situations where immediate delivery is indicated, yet performing a Cesarean section is unfeasible. These include the same indications as for a dead fetus.

Prerequisites for performing a craniotomy:

1. Cervical dilation of at least 6 cm.

2. Ruptured amniotic membranes.

3. Fetal demise.

4. True conjugate diameter of at least 6.5 cm.

5. Fetal head fixed at the pelvic inlet.

Required instruments: vaginal specula, bullet forceps or Museux forceps, Volkmann spoons or curettes, Bloch perforator, cranioclast, Siebold or Phenomenov scissors.

The procedure is performed under general anesthesia. Prior to the surgery, the Urinary Bladder must be emptied, and the external genitalia and vagina disinfected.

The surgical technique consists of three stages:

1. Cranial perforation.

2. Exenteration (excerebration).

3. Cranioclasis.

Cranial perforation is performed with the patient in the standard position used for all vaginal surgeries and comprises the following steps:

1. Insertion of specula into the vagina to expose the fetal head.

2. Grasping the scalp with forceps for fixation.

3. The perforation itself.

Cranial perforation

The fetal scalp between the forceps is incised transversely with scissors and slightly separated from the Skull bones. Under visual control, the perforator is introduced in a closed position into the area of a suture or fontanelle and opened to widen the perforation opening. In face presentation, perforation is performed through the Mouth; in brow presentation, through the Orbit; and in a aftercoming head, through the foramen magnum.

Excerebration

The operation of excerebration aims to remove the Brain tissue through a perforation opening. First, the brain is destroyed using a curette and then extracted with a large curette.

Cranioclasis

Cranioclasis is the procedure of extracting a perforated and volume-reduced fetal head using a cranioclast. If there is no need for extraction, the intervention is limited to perforation and excerebration, after which the fetus is delivered spontaneously.

The operation consists of three stages:

- insertion and placement of the cranioclast blades (the inner blade is introduced first through the perforation opening with its convexity facing the face; the outer blade is introduced second, following the same rules as the first blade, and is placed over the face);

- locking of the handles;

- extraction of the head (The Nature and direction of traction are the same as those used in obstetric forceps).

Perforation of the after-coming head is performed following the failure of manual assistance in cases of a dead fetus or Hydrocephalus.